Should organ donation registers move from an opt-in to an opt-out system?

Background and context

In the UK there is a presumption that individuals have not given consent to the use of their organs for transplant after their death. Individuals can ‘opt in’ to becoming donors by signing the NHS organ donor register. The final decision on whether a suitable organ may be used for transplant rests with the potential donor’s family. In other European countries including France, Belgium, Denmark, Finland, Italy, Sweden, Norway and Spain, there is an ‘opt-out’ system where individuals are presumed to have consented to have their organs used for transplant unless they specifically object. This may have a significant impact on the total pool of potential donors – in Belgium, for example, only 3%-4% opt out of donation. The British Medical Association has indicated its support for an “opt-out” system of presumed consent.

Argument #1

Yes

There is a serious shortage of organs for transplant in the UK, with about 5,600 people on the transplant waiting list but fewer than 3,000 transplant operations carried out every year. Although about 70% of the public say in surveys that they would be willing for their organs to be used by others after their death, only around 15% have signed the NHS organ donor register. Many organs are therefore buried or cremated when their owners would have wanted them to be used again, if possible. Moving to a system of presumed consent would enable those who object to the use of their organs to have their views respected, while ensuring the maximum possible donation rate from the rest of the population. Similar systems work in Sweden, in Spain (which has a "soft opt-out" system where the views of close relatives are taken into account) and in Austria (which has a "hard opt-out" system where relatives’ views are ignored). Spain has a higher number of donors than the UK and is the only country to have sustained a year-on-year increase in organ donation for the last ten years.

No

Withholding of consent is not the most significant factor in the current UK organ shortage. Seven out of every ten families approached do give their consent to the use of their relative’s organs for donation; refusal of consent where the donor has previously indicated a willingness to donate, such as with a donor card, is extremely rare. The biggest single factor in national organ donation rates is road safety: most donors are accident victims, as people who die of old age or disease tend not to have suitable organs for donation. Road accident statistics account for the much higher rate of organ donation in Spain than in Britain, for example. Other important factors, which this policy does nothing to address but which account for wide disparities between donation rates in different countries, include cultural attitudes to the disposal of bodies and the provision of intensive care beds. These national differences are reflected in the fact that, for example, Sweden has a lower donation rate per million population than the UK, despite the fact that it has an opt-out system.

Argument #2

Yes

Under the current system, the final decision over whether an organ is donated is made by the potential donor’s family. In many cases, family members may not know their relative’s wishes, and may offer an objection which the donor would not support - for example, they may hold beliefs about the importance of bodily integrity before burial which their relative rejected. Consulting the family is a denial of the donor’s autonomy.

No

Presuming consent and ignoring the wishes of the potential donor’s family could cause major distress to relatives and partners. This could lead to adverse publicity for the cause of organ donation. Offending the family’s feelings could also adversely affect their trust and respect for the medical profession. At death, the wishes of the victim’s family should be more important than those of the victim - they are, after all, still alive, and have to live with the consequences of any decision taken.

Argument #3

Yes

The death of a relative is always extremely traumatic. At this difficult time, families are not best placed to make the right decision on their relative’s behalf. It is wrong to place such a heavy extra burden on them, and better to leave it to the donor herself.

No

There could be medical risks with removing organs for donation without discussion with relatives. Relatives are an important source of information about the potential donor’s previous health, and are currently routinely questioned as part of the screening process.

Argument #4

Yes

Of course it is important to publicise this change in the law and make sure it is clearly understood. However, the nature of the new law is that it is the individual’s responsibility to make her own decision, and therefore her responsibility to acquaint herself with the way the law works - as with absolutely every other law.

No

An individual’s failure to withhold consent may indicate a lack of understanding of the procedure rather than agreement with the policy. There is therefore a danger that an individual may end up having her organs removed and used for transplant despite a real objection to such a procedure.

Argument #5

Yes

The number of donors in the USA has declined following an initial increase on the introduction of the "required request" rule. The key point about Spain is that, despite the fact that it routinely consults relatives, it operates an opt-out system and the wishes of the donor are key - it is an example on the proposition side. The only way of ensuring the maximisation of donated organs is to operate a strict opt-out system so that every suitable organ can be used for donation unless the donor specifically objects

No

There is no need to adopt this policy in order to achieve an increase in donated organs. In the USA the "required request" rule makes it mandatory to make enquiries into the possibility of organ donation before a life-support machine is switched off. This makes it less likely that opportunities for donation will be overlooked, but ensures that families continue to be involved in the process. In Spain, where a "soft opt-out" policy is in force, relatives are always consulted by a trained professional to ensure that they are aware of the possibility and implications of organ donation - this increases relatives’ willingness to allow the use of their loved-one’s organs, and their support for the donation programme.